2025 Adult Summer Camp Health Form
Last Name:
*
Legal First Name:
*
Middle Name:
*
Preferred Name:
*
Attended camp before?
*
A
Yes
B
NO
If attended how many years
Biological Sex:
*
A
Male
B
Female
Cell Phone Number:
*
Date of Birth:
*
T-Shirt Size
*
A
AS
B
AM
C
AL
D
AXL
E
A2XL
F
A3XL
G
A4XL
Email Address:
*
Yes - I would like to receive email notifications of upcoming statewide Camp=Sponsored Events and Promotions at the Email Address listed above
A
County:
*
Home Address
*
Participants Race
*
A
White
B
Black
C
Asian
D
American Indian
E
Hawaiian
F
Other
Participant’s Ethnicity:
*
A
Hispanic
B
Non-Hispanic
Emergency Contact Name:
*
Relationship to Participant:
*
Cell/Home Phone of emergency contact
*
Are there any specific behaviors, medical needs, dietary needs, accommodations, or information which the staff should be made aware of to provide a better camp experience for the participant?
Are there any specific behaviors, medical needs, dietary needs, accommodations, or information which the staff should be made aware of to provide a better camp experience for the participant?
Does the participant have health insurance coverage?
A
Yes
B
No
Insurance Provider
Insurance Provider
Provider's Phone
Provider's Phone
Policy Number
Policy Number
Group ID
Group ID
I am active duty military
A
Yes
AUTHORIZATIONS/RELEASES
Participant Signature
*
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Date
*
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